NYC Health + Hospitals/Community Care reaches outside the walls of our hospitals and brings health care to patients where they live. With more than 600 dedicated employees, Community Care provides services including home care, community care coordination, and community-based care management to individuals managing chronic health conditions residing in Brooklyn, Manhattan, Queens and The Bronx.
Provides services requiring substantial and specialized nursing skill and makes the initial evaluation visit to the client. Demonstrates competency in all skills required for the agency, including, but not limited to, wound care, catheter insertion, medication teaching, diabetic care, patient teaching and aseptic technique.
Evaluates, and regularly reevaluates, the nursing needs of the client; initiates, develops, implements and makes necessary revisions to the client’s plan of care. Completes comprehensive patient assessment on all patients including OASIS as indicated. Assesses the client’s continual care needs. Addresses all problems in the plan of care or documents rationale for not doing so
Initiates diagnostic, preventive and rehabilitative nursing procedures as appropriate to the client’s care and safety. Makes referrals to other disciplines in collaboration with the physician, client and family as indicated by the client’s needs or documents rationale for not doing so.
Observes signs and symptoms and reports to the physician and/or other appropriate health professionals as often as needed, or upon changes in the client’s condition.
Teaches, supervises and counsels the client and family regarding home nursing procedures and other care needs as appropriate to the client’s condition. Utilizes agency educational material as appropriate.
Coordinates the total plan of care and maintains continuity of client care by liaising with other health professionals assigned to the same clients. Attends client care conferences. Initiates client care conferences for complex and/or multidisciplinary clients whenever needed
Supervises and teaches the home health aide. Every two weeks, assesses the client’s need for unskilled care and revises the plan of care as appropriate. Communicates the plan of care changes to the aide and scheduler as often as necessary.
Develops, prepares and maintains individualized client care progress records with accuracy, timeliness and according to policies. Submits accurate documentation within 48-72 hours of visit. Completes 60 day summaries, discharge summaries, OASIS start of care, follow up and resumption of care forms, OASIS transfer, death at home forms as indicated.
Responsible for following all policies and procedures of the agency regarding service delivery, documentation and care coordination. During supervisory visits, exhibits full compliance and verbalizes knowledge of agency policies including but not limited to client education, infection control, and management of hazardous wastes and age-specific behaviors for clients.
Participates in the agency’s quality improvement program.
Participates in biweekly clinical record reviews as requested.
Assists with orientation of new staff.
Participates in mentoring of nursing and medical students as requested.
Attends agency provided in-service programs to fulfill requirements of position and agency policies.
Home visits daily. Weekly office meetings. Access to personal vehicle strongly preferred.
1. Licensed and currently registered to practice as a professional nurse in New York State
2. At Least One (1) year of experience in Homecare, Long-term Care, or Hospital setting
3. Demonstrated competence as a registered nurse in patient assessments and critical thinking skills
4. Demonstrated commitment to continued professional development
5. A satisfactory equivalent combination of education, training and experience
• Home Care experience preferred
• Computer Literacy
• Must be able to travel via private car with proof of car insurance or via public transportation
• Must be available to work calendar holidays on a rotational basis
• Must be available to work every other weekend.